Growth Plate Injuries

A physeal injury should be considered in any skeletally immature child with pain, swelling and tenderness over a growth plate after trauma, commonly at the distal radius, the distal tibia or fibula, the phalanges, or the distal femur. Point tenderness directly over the physis is the key finding, with reluctance to use the limb, or a visible deformity when the fracture is displaced. The examination should document distal pulses, capillary refill, skin colour and temperature, and the motor and sensory function of the relevant nerves (for example the common peroneal and tibial nerves around the knee and ankle), check the joint above and below, and compare with the other limb. Neurovascular status should be reassessed and recorded after splinting, after any reduction, and at handover.

Focal tenderness over a growth plate with a normal radiograph should be managed as a clinically significant injury, with support or immobilisation and follow-up along the site-specific pathway, because a Salter-Harris type I may not be visible on the initial film. Not every radiograph-negative injury is a true physeal fracture, however, and at low-risk sites such as the lateral ankle a ligament sprain is often the actual injury.

Plain radiographs of the relevant region are first-line, with at least two orthogonal views and site-specific additional projections when indicated, such as a mortise view for the ankle or oblique views for the hand, foot or some elbow injuries.

A Salter-Harris type I may show only soft-tissue swelling or subtle widening of the physis, so a normal film does not exclude it when there is focal physeal tenderness. A type II shows the metaphyseal (Thurston-Holland) fragment, while types III and IV cross the epiphysis and are intra-articular. A type V crush is usually diagnosed in retrospect, when growth disturbance appears. In adolescents with a distal tibial physeal injury, consider transitional fractures such as the Tillaux and triplane fractures: these are intra-articular injuries occurring around physeal closure that usually need urgent orthopaedic review, with computed tomography (CT) sometimes used in secondary care to define displacement. A comparison view of the other side can help when the physis is hard to interpret, but it should be used selectively, given the additional radiation. Magnetic resonance imaging (MRI) is reserved for secondary care, for occult or intra-articular injuries, or to plan surgery.

Management depends on the grade and the degree of displacement, with two guiding principles: restore anatomical alignment, especially for intra-articular fractures, and protect the physis from further injury.

Undisplaced Salter-Harris type I and II fractures are managed non-operatively with immobilisation in a cast or splint and planned follow-up, and most heal well. Displaced type I and II fractures need urgent emergency department or orthopaedic assessment; where reduction is required, it should be carried out by an appropriately trained clinician with adequate analgesia, and sedation where needed, followed by post-reduction radiographs and repeated neurovascular checks. Repeated or forceful attempts are avoided, since they can damage the germinal layer and increase the risk of growth arrest. Type III and IV fractures are intra-articular and generally require accurate reduction and often surgical fixation, so they warrant urgent orthopaedic referral, while a type V is usually recognised late, with management directed at the growth consequences.

If the fracture is open, cover the wound with a sterile saline-soaked dressing, avoid repeated exposure, give intravenous antibiotics as soon as possible according to local policy, splint the limb, and refer urgently through the local trauma pathway. Arrange fracture clinic follow-up along local paediatric pathways, with short-interval review for low-risk undisplaced injuries and longer clinical and radiographic surveillance for displaced, intra-articular or high-risk injuries and any suspected growth disturbance, which may not appear for many months. Give families clear safety-net advice to return for increasing pain or swelling, altered sensation or colour, a tight cast, fever, or a failure to regain function.

Physeal fractures generally heal faster than equivalent adult fractures, and most children recover fully and return to sport. After the period of immobilisation, rehabilitation restores range of movement and then strength, with return to sport once the fracture has healed and movement and strength are full and pain-free. Even after union, occasional review confirms that growth is progressing normally, since a partial arrest can declare itself later as an angular deformity or a difference in limb length.

Repetitive physeal stress injuries, such as distal radial physeal stress in gymnasts or physeal overload around the throwing shoulder and elbow, are a separate, overuse pattern. They are usually managed with sport-specific load reduction, relative rest from the provoking activity, rehabilitation of contributing kinetic-chain factors, and a graded return, although temporary splinting can help in selected painful wrist cases.

• •The Salter-Harris classification is the standard framework that links the fracture pattern to prognosis and guides management.
• •Relevant British Orthopaedic Association Standards for Trauma, including those on paediatric forearm fractures, open fractures and compartment syndrome, inform UK assessment, documentation, timing of treatment and escalation.
• •National Institute for Health and Care Excellence (NICE) guidance on fracture assessment and management, and on when to suspect child maltreatment, supports decision-making and safeguarding.
• •The risk of growth disturbance rises with a higher Salter-Harris grade, with physeal crush, and at higher-risk sites such as the distal femur.

• •Salter-Harris types: I through the physis, II exits the metaphysis (commonest, with a Thurston-Holland fragment), III exits the epiphysis, IV crosses all three, V is a crush.
• •A Salter-Harris type I can have a normal radiograph, so treat physeal tenderness after trauma as a clinically significant injury.
• •Higher grades (III to V) and physeal crush carry the greatest risk of growth arrest and deformity.
• •Avoid repeated or forceful manipulation, which can further damage the growth plate.
• •Distal femoral physeal injuries carry a high neurovascular and growth-arrest risk; in adolescents, also consider Tillaux and triplane ankle fractures.
• •A metaphyseal corner or bucket-handle fracture in an infant suggests non-accidental injury.